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Posted April 26, 2006

Ask An Expert

Finances: Handling Nursing Home Reimbursement Issue

Q. In reviewing my most recent bill for the nursing home where my mother is, I see charges for her oxygen concentrator, wound care items, a special mattress, etc. When she was at home, some of these items were covered by her combination of Medicare and private insurance. Is this different in the nursing home? Do I need to submit the bill with these items underlined for reimbursement or payment from Medicare/BC/BS? I had assumed the nursing home would submit the appropriate forms to Medicare/ BC/BS before billing me (or my mother). What should I do?

Cheryl M., Purcellville, VA

A. I'm assuming that you are speaking about a private pay resident, because when a resident is covered under Medicaid, charges are covered in an all-inclusive rate.

For private pay residents, nursing home bills use a basic rate for room and board, and apply additional charges for doctors' services; laboratory tests; physical, occupational and speech therapies; equipment; and prescription drugs. Medicare and private insurance cover many -- but not all --of the added charges.

If you review the admissions agreement you signed, you will quite likely find a clause stating that residents are responsible for paying all ancillary charges above and beyond basic room and board. Although the facility must supply all supporting documentation, it is not their responsibility to arrange for reimbursement -- or to secure your prior approval for purchases they deem important to her care.

If you are having difficulty obtaining reimbursement, I suggest you contact a geriatric care manager or a senior money management firm in your area. They are experts in collecting money from Medicare and private insurance companies.

This answer is provided by Jack Halpern, MPS, LNHA, an eldercare advocate and a licensed nursing home administrator. Halpern, a nationally recognized expert on eldercare issues, is the author of many articles on eldercare and nursing home abuse, and is the CEO of My Elder Advocate.

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